Provider Demographics
NPI:1134999741
Name:CORNELIOUS, CAMILLE (LAC)
Entity type:Individual
Prefix:
First Name:CAMILLE
Middle Name:
Last Name:CORNELIOUS
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:CAMILLE
Other - Middle Name:
Other - Last Name:NEALEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:N/A
Mailing Address - Street 1:3050 W AGUA FRIA FWY STE 150
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85027-3998
Mailing Address - Country:US
Mailing Address - Phone:623-332-8002
Mailing Address - Fax:623-234-4774
Practice Address - Street 1:3050 W AGUA FRIA FWY STE 150
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85027-3998
Practice Address - Country:US
Practice Address - Phone:623-332-8002
Practice Address - Fax:623-234-4774
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-04
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-21261101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health